Related Experiment Video
Updated: Sep 25, 2026
Development and Implementation of a Multi-Disciplinary Technology Enhanced Care Pathway for Youth and Adults with Concussion
Published on: January 20, 2019
Estimating pediatric primary care provider visits in a capitated environment: encounter vs. claims databases
Ernest P Schloss1, Vicky Lewis, Nancy Martin
1Children's Clinics for Rehabilitative Services, 2600 N. Wyatt Drive, Tucson, AZ 85712, USA. ernie.schloss@tmcaz.com
Insights
Insurance claims data underestimate primary care visits for children with special health care needs (CSHCN). Encounter data reveal significantly higher utilization, suggesting claims data are inaccurate for assessing CSHCN care access.
Area of Science:
- Health Services Research
- Pediatric Healthcare
- Health Informatics
Background:
- Children with Special Health Care Needs (CSHCN) often have complex care requirements.
- Accurate tracking of primary care provider (PCP) utilization is crucial for ensuring adequate healthcare access for CSHCN.
- Existing insurance claims data may not fully capture PCP encounters for this population.
Purpose of the Study:
- To assess the accuracy of insurance claims data in reflecting primary care provider (PCP) utilization among children with special health care needs (CSHCN).
- To compare the completeness of PCP visit data between insurance claims and encounter databases for CSHCN.
Main Methods:
- Retrospective analysis of 1,131 CSHCN enrolled in Medicaid and commercial health maintenance organizations (HMOs).
- Comparison of primary care provider (PCP) visit data extracted from electronic claims-and-encounters databases over a one-year period.
- Data collected from specialty care clinics serving CSHCN in Arizona.
Main Results:
- Insurance claims data indicated only 14% of CSHCN utilized PCP services within a year.
- Encounter data revealed that 59% of the same CSHCN cohort had PCP visits.
- A significant discrepancy exists between claims and encounter data regarding PCP utilization for CSHCN.
Conclusions:
- Encounter databases provide a more comprehensive record of primary care provider (PCP) visits compared to insurance claims databases in capitated healthcare settings.
- Insurance claims data may lead to an underestimation of primary care access for children with special health care needs (CSHCN).
- Improved data capture methods are needed to accurately monitor healthcare utilization for vulnerable pediatric populations.
Purpose:
To evaluate the accuracy of insurance claims data indicating underutilization of primary care visits by children with special health care needs (CSHCN).
Design:
The study was a retrospective comparison of primary care provider (PCP) utilization by 1,131 CSHCN, using secondary data from electronic claims-and-encounters databases in a Medicaid health maintenance organization (HMO) and a commercial HMO.
Methodology:
The study was conducted at the Children's Clinics for Rehabilitative Services (Children's Clinics) in Tucson, Ariz., a provider of specialty care to CSHCN. All the children in the study were eligible for specialty services under Arizona's statewide program for CSHCN and were simultaneously enrolled, from Oct. 1, 1995 through Sept. 30, 1996, in either one or both of the managed care plans for their primary care. Identical PCP-visit information for the same 1-year period was collected from the plans' claims-and-encounters databases, and the number of primary care visits as computed from both databases was compared.
Principal Findings:
Health plan claims data show that only 14 percent of the patients visited a PCP during the course of a year. The encounter data indicate that 59 percent of the same cohort had PCP visits.
Conclusions:
Encounter databases capture more information about PCP visits than insurance claims databases in capitated environments.
More Related Videos
06:55Inverse Probability of Treatment Weighting (Propensity Score) using the Military Health System Data Repository and National Death Index
Published on: January 8, 2020
06:16Signal Acquisition, Score Interpretation, and Economics of a Non-Invasive Point-of-Care Test for Coronary Artery Disease
Published on: August 9, 2024
Related Concept Videos
01:26Methods Of Healthcare Delivery System
Managed Care System:
The managed care system is designed to control the cost while maintaining the quality of care. The patient's care from admission to discharge is planned by the primary care provider or the case manager, also known as the gatekeeper. In a managed care system, the number of care providers is limited...
01:30Primary Healthcare Services
In 1978, international leaders convened in Alma-Ata, Kazakhstan, for what would be a pivotal event in global health. The Alma-Ata Declaration was the first to call...
01:15Methods of Documentation VI: Case Management Model
For example, a patient with a chronic illness...
01:30Methods of Documentation VII: EMR
01:30Health Information Technology and Healthcare Information System
Health Information Technology, commonly called HIT, integrates advanced information systems and technology in healthcare settings. Its primary functions include:
01:24Kaplan-Meier Approach